Mandatory Fields are marked with an asterix (*).

Data Protection
During our conversation or meeting we will complete a detailed Fact Find to enable appropriate advice to be given to you for a mortgage and/or other related insurance products.   Our company is an Appointed Representative of Genesis Home Loans PLC who will process all information in accordance with the Data Protection Act 1998 and it will be treated as private and confidential now and in the future. The only exceptions to this will be when the law requires us to disclose information or, with your consent, where disclosure is necessary when arranging or servicing your mortgage or protection contracts.   To fulfill our regulatory obligations, we will retain copies of your records for no longer than is necessary or for the duration of the contract. You have the right to inspect these records at any time. We may make a charge of up to £20 to provide your records.   I have read, understood and agree to the above Data Protection Declaration * (Mandatory, please tick in order that we an deal with your enquiry)
Our Future Relationship
Our business relationship with you is important and we would like to be able to contact you by telephone, post or email from time to time to review your mortgage, associated protection products and other services that may be of interest to you. I agree to further contact as described above * (Mandatory, please tick in order that we an deal with your enquiry)
Enquiry Details
Title *	- select - Mr Mrs Miss Ms Sir Dr Prof Rev
Full Name *
Email Address *
Telephone Number
Full Postal Address
Area of Interest *	- select - Mortgage Property insurance Payment protection insurance Life insurance Conveyancing All services
Purchase Price / Valuation (£)
Amount to be borrowed (£)
Type of Lending	- select - Homemover Remortgage First Time Buyer Buy to Let Credit Repair 100% Mortgages Shared Ownership Right to Buy
Purpose of Capital Raising	- select - Home improvements Debt consolidation Other
If Other, please specify
Existing Lender Name
Existing Loan Balance (£)
Do you have problems with repayments ?	- select - None Mortgage Arrears Mortgage Arrears Defaults
Additional Comments
Preferred method of contact. please tick all that apply	Telephone Email Post
Thank you for taking the time to complete the enquiry form. Once you are happy the information is accurate press submit.